• Coding for a Concussion

    Question: We have a patient with a history of concussions from football, however no specifics pertaining to these concussions. He has visual field defects and we need to know if we have to code the concussion. If so, how would we code this?

    Answer: Code first the visual defects as primary. The concussion code would be listed secondary as this is informational only.

    Concussion codes are S06.0X- depending on the amount of time the patient lost consciousness. S06.0X9- Concussion with loss of consciousness of unspecified duration (Concussion NOS). Remember that the 7th final character will need to state encounter status.